Gluteal abscess caused by Mycobacterium tuberculosis
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Gluteal abscess caused by Mycobacterium tuberculosis J. Swol1 · J. Boehm1 · R. Jakoubova1 · J. H. Ficker1 Received: 12 September 2020 / Accepted: 6 October 2020 © Springer Nature Switzerland AG 2020
Dear Sir, Given the rarity of tuberculosis (TB) infections of soft tissues we would like to share with the readers the case of a 59-year-old female from Eritrea who presented with a large mass in the left gluteus maximus muscle. Her medical history was positive for hepatitis B. Chills and fever were absent, but reduced appetite and cachexia were recorded. The cystic formation with multiple thick septa was identified by ultrasound and verified by computed tomography (CT) scan (Fig. 1). Aspiration of the fluid collection revealed purulent material. Acid-resistant rods were detected with Ziehl–Neelsen staining, which were confirmed as Mycobacterium tuberculosis based on polymerase chain reaction (PCR). Surgical removal of the abscess was performed. Staphylococcus aureus, Finegoldia magna, and Atopobium parvulum were also detected in microbiology cultures. Furthermore, rifampicin resistance was detected by PCR, and therapy with moxifloxacin, isoniazid, ethambutol, and pyrazinamide was started. A CT scan of the chest showed no evidence of pulmonary TB. No acid-resistant rods were found in the sputum or bronchial lavage. To rule out TB of the intestinal tract, gastroscopy and colonoscopy were performed, and no histopathological or morphological evidence of tuberculosis was detected. No primary localization was found and no notion of iatrogenic inoculation was noted.
Due to resistance to rifampicin, isoniazid, ethambutol, and pyrazinamide and multi-drug resistant (MDR) TB, the therapy was switched to moxifloxacin, terizidone, pyrazinamide, and meropenem. Neutropenia developed over the treatment course, which is why moxifloxacin was paused. The patient developed a urinary tract infection with evidence of E. coli and was treated with fosfomycin. Another complication was a port infection. A subsequent maintenance therapy for 18 to 24 months was continued with moxifloxacin, terizidone, and pyrazinamid. Muscular TB is rare (0.01–2%) and its exact pathogenesis is not yet clearly explained. Also, its occurrence without associated bone involvement is exceptional. TB should be considered in patients who present with unexplained soft tissue swelling and pain, and were foreign born in an endemic area. It may take inordinately long to arrive at the appropriate diagnosis and start treatment. Actively searching for predisposing factors, exposure risks and specific clinical clues may speed up the diagnostic process. Ziehl–Neelsen staining, based on PCR is essential to determine the species and strain of mycobacterium, with important consequences for treatment. Multi-drug resistance (MDR) and its exact pathogenesis were not yet clearly explained in this patient. The prognosis is good if appropriate therapy is administered, and the patient fully recovered.
* J. Swol [email protected] J. Boehm jochen.boehm@klinikum‑nuernber
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